H1N1 Crisis Could Swamp Intensive Care Units

Oct. 12, 2009 — -- In hospitals, ventilators are among the MVPs for patients in need of both acute and long-term care.

Ventilators keep people in comas alive, help those who cannot breathe get enough oxygen and those who have suffered heart attacks recuperate, and ease normal breathing in asthma patients, among a multitude of other uses.

But in a crisis, if H1N1 infections burgeons out of control, for example, the need for ventilators and other critical equipment might exceed the available resources, public health officials warn.

Adding fuel to these concerns is a report, published this morning in the Journal of the American Medical Association, showing that the pandemic virus has already strained intensive-care unit resources in other North American countries.

Specifically, intensive-care units in Canada and Mexico were at full stretch during the peaks of the spring pandemic H1N1 flu outbreak, researchers said.

In Winnipeg -- site of the largest cohort of pandemic patients in Canada -- all intensive-care beds were occupied with H1N1 flu patients when the outbreak peaked in June, according to a study led by Dr. Anand Kumar, ICU attending physician for the Winnipeg Regional Health Authority.

And, in Mexico city, six major hospitals were so busy that admission to intensive care was delayed, and four patients died in the emergency department before they could get to the the ICU, according to a study led by Dr. Guillermo Domínguez-Cherit of Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán."

The papers are the first to report on a large group of critically ill H1N1 patients treated during the early days of the pandemic in North America.

Meanwhile, Australian and New Zealand researchers reported last week that their intensive-care units were also under pressure as a result of the pandemic.

The papers underscore an unsettling reality -- that in an effort to ration resources during an emergency, health officials may be in the difficult position of determining, essentially, who lives and who dies.

"We have a lot of ventilators in the U.S., but somebody's on them all the time," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "You're basically talking about taking somebody off a ventilator to give it to somebody else."

Late last month, the Institute of Medicine released guidelines for crisis standards of care that included recommendations on how to allocate life-saving resources -- such as ventilators -- in an emergency while maintaining ethical standards.

"Depending on the disaster, ventilators are something you could need and could run out of," said Dr. Tia Powell, director of the Montefiore-Einstein Center for Bioethics and one of the authors of the IOM report. "But no one thinks that is likely with H1N1."

Other resources, Powell said, that may need to be rationed carefully include oxygen, tubing of various sizes and antibacterial or antiviral medications.

Public health experts agree that swine flu will not be an overwhelming pandemic in the way that the 1918 influenza pandemic, which killed more than 50 million people, was. Antiviral vaccine development is well under way, and public awareness about H1N1 influenza is increasing.

But disaster situations require doctors to make decisions where providing the best individual care may conflict with the duty to steward resources to save the greatest number of lives.